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If they could only come up with treatments which stopped this disease in its tracks, then they would not have to deal with the psychological problems that come with this disease!

Pilot program overcomes barriers to psychological care in MS patients

The attempted suicide of a young man was the catalyst for change in the way treatment is offered to multiple sclerosis patients at Medical College of Georgia (MCG), a change that may have implications for patients beyond Augusta diagnosed with chronic illness.

“I had seen him within the last week,” said Dr. Mary Hughes, a neurologist and director of the Augusta Multiple Sclerosis Center. “My nurse had seen him, and we had picked up on nothing. We were all just dumbfounded.”

“When someone is diagnosed, it is a major life change,” said Dr. Sarah Shelton, a postdoctoral psychology fellow in multiple sclerosis at the center. “Patients have to learn a lot of information about their disease and go through the process of acceptance that every facet of their life could be altered significantly. It’s a huge transition.”

Possible lifestyle changes include loss or change in job status, which can lead to a drastic financial adjustment and a loss of identity. Personal relationships are affected as the patient and family members adjust to the disease.

The suicide rate in patients with multiple sclerosis is seven times that of any other population. Fifty percent of patients are diagnosed with depression. At the time of her patient’s suicide attempt, reports of increasingly high rates of depression, mood disorders and suicidal ideation in the MS population were being published, and Dr. Hughes went looking for solutions.

She found Dr. Lara Stepleman, an assistant professor of psychiatry in the Department of Psychiatry and Health Behaviour, who had a strong interest in chronic medical illness care and was directing a program focused on the mental health needs of HIV patients. The two assessed needs of MS patients to determine how a psychology consult service could best help them, co-founding MS Psychology Consultation Services in 2003.

Key to the program is the on-site availability of psychology services. Traditional mental health settings are under-utilised by MS patients for several reasons.

Mobility plays an important role in multiple sclerosis. Multiple appointments in numerous locations can strain transportation budgets and energy levels, lessening the chance of patients receiving the service they need as symptoms of their disease fluctuate.

The potential stigma of seeing a mental health provider decreases when psychological services are accessible during regular appointments. “Sometimes people don’t understand the many stressors that come along naturally as part of having a chronic illness, or that some of the symptoms of MS can cause psychiatric issues,” explains Dr. Stepleman. “Having it integrated as part of normal medical appointments makes it much more acceptable.”

A patient’s emotional state has a vital connection to his physical health when treating a disease like multiple sclerosis that requires compliance and adherence to a strict medical regimen. “If they are so depressed that they are not motivated or invested enough to follow that regimen, their health is going to be directly affected,” said Dr. Shelton.

On-site psychological services also allow inclusion of people who typically bring patients to their appointments – spouses, parents, children and other caregivers who are themselves at high risk for mental-health problems.

Integrated medical and psychological services benefit providers as well. “Dr. Hughes helps me understand how the disease is medically affecting the patient’s emotions, cognitions or thoughts,” said Dr. Shelton, “and I help her understand some of the personality, situational and psychological factors that might be presenting. If you have separate services, the providers don’t get that complete picture, they only see half, which is a false dichotomy because the medical and psychological really work together.”

Dr. Hughes concurs: “By keeping a psychologist involved when physicians are doing screening evaluations, it increases our effectiveness because of our different training, our different skills.”

“This is really unique. In 95 percent of clinical services, you won’t find this level of integration,” said Dr. Stepleman. “Some programs have psychologists, but they’re not actively involved at the same time the medical treatments are being done.”

Beginning with one clinic a week in 2004, Dr. Hughes and Dr. Stepleman committed themselves to the psychology consultation service without funding. “It was one of those ‘If you build it, they will come’ things,” said Dr. Hughes. The project received Quality of Life grants from the Multiple Sclerosis Foundation and the Christopher Reeve Foundation and a research grant from MCG’s Combined Intramural Grants Program in 2005, allowing expansion.

The clinic’s escalating reputation for a full range of services with a high level of quality and responsiveness has fueled tremendous growth. “Patients come with an awareness of what we’re able to do,” said Dr. Hughes. The center now follows over 1,500 people with multiple sclerosis, with a psychology presence at five weekly clinics. Dr. Shelton came on board in August 2005 to manage day-to-day issues, treat patients and assist in training residents. Monthly interdisciplinary team meetings address clinical, educational and research aspects of the collaboration, and a monthly support group has begun, drawing patients and caregivers who may drive as long as two hours to attend.

“The question hasn’t been, ‘Do we recognise this need?’” said Dr. Hughes. “It’s been, ‘How do we meet this need?’ The challenge is with mental health coverage. It’s the classic issue of limited resources in health care.”

“That’s why getting these grants is so important,” added Dr. Shelton. “We’re able to provide psychological care at little or no charge without billing the insurance company. That allows us to provide quality comprehensive care in a way and a place the patient can receive it.”

Since January, funding has provided for 300 depression screenings, 146 psychological consults, 108 psychotherapy/counseling sessions and 34 specialised psychological and cognitive testings. In addition to the consultation services, a two-year study based on a five-session problem-solving model for MS patients also diagnosed with clinical depression began in February to learn how to better meet patients’ needs.

Other treatment providers are taking notice and visiting the Augusta Multiple Sclerosis Center. “People are fascinated with how we are trying to address this need,” said Dr. Hughes. “They have the same need in their clinic setting, but they’re all struggling with how to meet it. The leap from identifying the need to what’s the best way to provide those services is the gap that we’re trying to learn to fill.”

As leaders in developing the innovative programming model, Drs. Hughes, Shelton and Stepleman are presented last week at the 22nd European Committee on the Treatment and Research of Multiple Sclerosis in Madrid, Spain, on two topics: Predicting depression and anxiety in a multiple sclerosis clinic population: the contributions of illness severity, illness management and perceived cognitive impairment; and Overcoming mental health care barriers for individuals with multiple sclerosis: innovations in psychological consultation.

“We want to be able to spread this information so that other clinics learn from our experience,” said Dr. Hughes. “Unfortunately, we started with a crisis and worked backwards. Fortunately, the young man who had attempted suicide is now doing well. We’d have much rather been preventive. Part of what we were interested in when we developed this model was to make it applicable to various settings, and so while we were concentrating on multiple sclerosis, in the future, we’d be interested in implementing it in Parkinson’s disease or dementia or other chronic care clinics. You see enormous need and we really want to be able to pass on this information to people who can benefit from the work we’re doing here at MCG.”

It's funny that the Dr. says her and her nurse did not pick up on the depression. As for my Dr. and RN, they didn't seem like they picked up on anything either when I could not stop crying my eyes out in front of them. They just stared at me and said that I have to chose a medication and that none of them were really all that great so it didn't really matter which one I picked. I guess they were helping make the decision easier NN

I recently had a session of hypnosis which I found very beneficial in terms of addressing the stress of MS. I'll be having further sessions. Hypnosis may be something others have tried or may like to try.

Anything that underlines the mental and emotional impact of a diagnosis of ms is worth the print space altho it is a case of stating the obvious. Any person given a dx of ms, a disease with no established cause or cure, with question marks over the available disease modifying drugs, bouts of or sometimes permanent severe disablity and an uncertain outcome is bound to react negatively. Shaun, I am so sorry to hear of your experience.
Muu

Here's what I'm wondering: Is the cause of depression in people with MS situational (i.e., it's in response to having and coping with the disease) or is it organic (i.e., the disease affets the brain in a manner that promotes depression). I've suffered with depression my whole life, and in a twisted way it makes me feel better to think that MS is the physical cause of my depresion. Does anyone know whether there's research available about this question?

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